Synopsis At 1405 on 29November 1993, a Port State Control Inspection was being carried out aboard the IRAN SALAM berthed at Section 50 of the Port of Montreal, Quebec. While the gravity davits of the starboard lifeboat were being tested, the lifeboat fell free on to the wharf. The two crew members who were on board the lifeboat sustained serious injuries and had to be hospitalized. The Board determined that the lifeboat connections in way of the lifting hook base plates were corroded by rust and failed under the weight of the lifeboat when the gripes were removed. Lack of attention to detail during the inspection for the issuance of a Cargo Ship Safety Equipment Certificate contributed to the accident. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The IRAN SALAM is a general cargo with the accommodation, bridge and engine-room amidships. On either side of the accommodation, a lifeboat is hung from gravity davits on roller tracks. This vessel is used mainly for international shipping, and was making her first voyage to Canada. 1.1.2 Description of the Lifeboat The lifeboat was built in 1975 at the Ustka shipyards in Poland. It is made of reinforced plastic and fitted with an internal combustion engine developing 17.9kW, and it is 8m long, 2.85m wide, and 1.15m deep. Its loaded weight is 8,585kg, and it can accommodate up to 56 persons. The working load of the lowering and hoisting mechanisms at either end of the lifeboat is four metric tonnes. Each connection at either end of the lifeboat is fitted with a lifting hook and attached to a metal base plate bolted to the keelson. The connections are 7.6cm wide and 0.9cm thick in way of the metal base plate. The starboard lifeboat is hung from a gravity davit on roller tracks and is secured in its stowage by gripes at either end. The gripes are made of steel wire rope and are 9.5mm in diameter. They are fitted with a slip hook for manual release at their lower end and with a shackle at their upper end. The gripes are adjusted using a turnbuckle, the threaded part of which is secured by a shackle attached to the davit frame, and the other end, the turnbuckle eye, to the gripe shackle. To release the gripes aboard the IRAN SALAM, crew members must climb aboard the lifeboats and unscrew the turnbuckles until the threaded part disengages. 1.2 Sequence of Events At about 1405(3) on 29November 1993, the IRAN SALAM was berthed at Section 50 in the Port of Montreal. Two Canadian Coast Guard (CCG) inspectors boarded the vessel to carry out an inspection under the Port State Control Program, which is designed to ensure compliance with international conventions relating to safety standards aboard vessels. The inspection of the life-saving equipment to be carried out included the testing of the gravity davits. After the port lifeboat was checked, the starboard lifeboat was to be inspected. The master of the IRAN SALAM was reluctant to lower the lifeboat as the vessel was berthed starboard side to. However, as he was required to comply with the inspection requirements, the master ordered the starboard lifeboat readied. Two crew members climbed aboard the lifeboat to get it ready for testing. The gripe adjustment turnbuckles fitted at either end of the lifeboat and used to secure it on the davit had to be removed before the boat could be lowered. The gripe at the bow of the lifeboat was removed without difficulty, but when the stern gripe turnbuckle was removed, the lifeboat fell free from a height of 7.6m. The lifeboat crashed on to the wharf, taking one of the two crew members with it; the other crew member fell 3.7m and landed on the vessel's boat deck. The two crew members were seriously injured and were given first-aid treatment. One had to be given artificial respiration and a cardiac massage before the two injured crew members were transported to a local hospital by ambulance. 1.3 Injuries to Persons Only the two crew members who were aboard the starboard lifeboat were injured as a result of this occurrence, and they had to be hospitalized. 1.4 Damage 1.4.1 Damage to the Vessel 1.4.2 Damage to the Lifeboat The starboard lifeboat sustained considerable damage when it crashed on to the wharf. The propeller and propeller shaft were bent in the impact, pieces of fibreglass broke off in some places, and the grab rails along the outside of the hull failed. The lifeboat was repaired and put back in service before the IRAN SALAM departed. 1.4.3 Inspection of the Lifeboat Connections by the TSB Engineering Laboratory The TSB Engineering Laboratory carried out a photogrammetric examination to determine the condition of the lifting hook connections. The lifting hook connections on the starboard lifeboat were in an advanced state of corrosion, especially the connection of the after lifting hook which had deteriorated further than the forward connection. Analysis of the connection metal plates indicated that, in way of the point of failure, the two plates comprising the after connection were 1.03mm and 1.12mm thick, respectively, and those comprising the forward connection were 1.48mm and 1.84mm thick, respectively. These metal plates are normally 0.952cm thick. The failure of the forward and after connections occurred 7.62cm from the lifting hook base plate. In addition, discoloration was observed on the inside surface of the lifeboat, indicating an accumulation of water in the bilges, which could have contributed to the corrosion at the base of the connections. 1.5 Certification 1.5.1 Vessel As a prerequisite for the issuance of a Cargo Ship Safety Equipment Certificate to the IRAN SALAM, an inspection of the vessel's safety equipment was carried out on 22October 1992 in compliance with the requirements of the International Convention for the Safety of Life at Sea, 1974 (SOLAS). At that time, several shortcomings, deficiencies and defects were noted which affected safety, including the section relating to the inspection of lifeboats (item G.11 of the Lloyd's survey checklist), which requires that all sheaves, blocks, falls, lifting hooks, hook foundations and securing arrangements, and all moving parts be found free and well lubricated or made good at the time of survey. A total of four inspections were carried out while the vessel was in different ports in October 1992, December 1992, February 1993 and March 1993. The certificate issued in October 1992 mentions shortcomings related to parts on the port and starboard lifeboats, including the fall blocks and limit switches, but there is no mention of the connections of the starboard lifeboat. During a second inspection by the same inspector, in December 1992, it was found that the previously noted shortcomings as per the checklist had been corrected and were satisfactory, except for the limit switches. However, as other items on the checklist were still outstanding, a short-term certificate was issued for a period of one month so that they could be corrected. In May 1993, a Cargo Ship Safety Equipment Certificate was issued in London, United Kingdom, for the IRAN SALAM with an expiry date of 21October 1994. At the time of the accident, the IRAN SALAM therefore held a valid Cargo Ship Safety Equipment Certificate. 1.5.2 Lifeboat The certificate for the starboard lifeboat had been issued on 28January 1975 at Ustka, Poland, in accordance with the SOLAS Convention. 1.5.3 Personnel The master and all officers held the certificates appropriate for the class of vessel on which they were serving and the voyage being undertaken. 1.6 Weather Information At the time of the accident, the weather was clear, the air temperature was 1C and the winds were light. Weather is not considered to have played a role in this accident. 1.7 Radio Communications A few minutes after the accident, a crew member reported the accident to the Vessel Traffic Centre (VTC) at Montreal by radiotelephone and requested that an ambulance be sent to the site. An ambulance was dispatched by the Marine Rescue Sub-centre (MRSC) at Qubec. The two injured crew members were transferred to a local hospital.